Personal Physicians? Larry A. Green, MD Professor and Epperson Zorn - - PDF document

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Personal Physicians? Larry A. Green, MD Professor and Epperson Zorn Chair for Innovation in Family Medicine and Primary Care Association of Departments of Family Medicine I want to thank ADFM and the conference planning committee for inviting me back to this year’s meeting. I hold department chairs in a special place in my heart, surrounded there by gratitude for what you do, and especially my own department chairman, Dr. Frank deGruy. You ladies and gentlemen are special people, power players in the structures of Academic Health Centers and health care delivery systems, facing hard choices concerning the use of the very substantial resources you manage and sometimes control. You do so while serving multiple masters and dealing with an unusual scale and pace of constant change in the medical-industrial complex that now dwarfs all other sectors of our society. The health care industry dominates the economy

• f the richest nation on the planet. You and your predecessors fought hard to be a

legitimate part of this amazing complex, and academic departments of family medicine now dwell within it as it produces a dazzling array of knowledge, technology, and services provided by a giant and growing workforce. This unprecedented enterprise thrives on insatiable consumption of its products by a public expecting to be cured of their diseases and relieved of their suffering and investors expecting a return on

• investment. I know you yearn to lead your departments to help advance affordable

healthcare that actually produces health and that you have important ideas about what that means. I lack confidence, however, that departments of family medicine have discerned and agreed on what if anything they MUST do to help create proper versions

• f health care—because they are indeed departments of family medicine, not

departments of population health, primary care, adult medicine, ambulatory care, health care management, PCMH’s. My aim with this presentation is to stimulate chairpersons of academic departments of family medicine and their colleagues to think about whether or not in the coming years the people of the United States will have a doctor, and more specifically if there will be a place and a role for the personal physician in the health care organizations now evolving into the information age. If so, what is that place and role—and—most importantly, what might such a personal physician promise to do, to be, for her or his

• patients. I hope you will join together in a few minutes in conversation about this

question, not dismissing it as rhetorical, narcissistic, or nostalgic. Rather, I hope you

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will think carefully about this question so you can decide for your department whether or not it will contribute to producing the best personal physicians in human history or if instead, you will guide your department to steward your resources to contribute to preferable replacements for personal physicians, such as call centers, navigators, health coaches, spiritual advisors, interdisciplinary teams, interprofessional teams, pcmh’s, aco’s, avatars, robots and nanobots, machine counseling, google and amazon- health, and IBM’s Watson. Here we go. What is a personal physician? We know that many people have no idea, having never spotted one in the wild, including many residents and students, including family medicine residents. Some of you will recall the Future of Family Medicine finding more than a decade ago that a representative sample of the US population really wanted a physician they could go to with any problem who would stick with them—and also that they seemed to not exist anymore. In 1960 T. F. Fox published a characterization of the personal physician in the Lancet, used to guide the recent initiative known as Preparing the Personal Physician for Practice, P4. He wrote using masculine pronouns:

The doctor we have in mind, then, is no longer a general practitioner and by no means always a family practitioner. His essential characteristic, surely, is that he is looking after people as people and not as problems. He is what our grandfathers called “my medical attendant” or “my personal physician”; and his function is to meet what is really the primary medical need. A person in difficulties wants in the first place the help of another person on whom he can rely as a friend—someone with knowledge of what is feasible but also with good judgment on what is desirable in the particular circumstances, and an understanding of what the circumstances are. The more complex medicine becomes, the stronger are the reasons why everyone should have a personal doctor who will take continuous responsibility for him, and, knowing how he lives, will keep things in proportion—protecting him, if need be, from the zealous specialist. The personal doctor is of no use unless he is good enough to justify his independent status. An irreplaceable attribute of personal physicians is the feeling of warm personal regard and concern of doctor for patient, the feeling that the doctor treats people, not illnesses, and wants to help his patients not because of the interesting medical problems they may present but because they are human beings in need of help. [Ref Fox TF. The personal doctor and his relation to the hospital. Lancet. 1960;2:743–760.

There are other candidate definitions. For example: “A personal physician is a doctor in active medical practice who grants his patients direct access to him as their initial source of medical care.” This definition stands in contrast to an accompanying definition

• f a specialist, “A specialist is a physician who predetermines the kind of disease which

his patients can have.” Yet another version is: “The personal physician is the first

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contact physician who gives continuing care, who takes continuing responsibility and is readily available to his patients.” With these definitions in mind, for our purposes, there is no need to belabor all the variations to be found, nor to fret over the distractions produced by other concepts known as principle physician, primary physician, general practitioner, family physician, primary care physician, and the unfortunate acronym “PCP.” There is, however, a need to have some shared understanding amongst us as to the role that a personal physician might fulfill. Fortunately, thanks to extraordinary efforts by Dr. Robert Phillips et al and the considerations of the national organizations of family medicine involved in Family Medicine for America’s Health, we have a published role definition for family physicians that can be used for our purposes now because it states that “family physicians are personal doctors:”

“Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health.” [Ref: Phillips RL Jr, Brungardt S, Lesko SE, et al. The future role of the family physician in the United States: a rigorous exercise in definition. AnnFamMed 2014;12:250-5]

These authors helped everyone understand this proposed role by contrasting it with what they called a foil role definition:

“The role of the US family physician is to provide episodic outpatient care in 15-minute blocks with coincidental continuity and a reducing scope of care. The family physician surrenders care coordination to care management functions divorced from practices, and works in small, ill- defined teams whose members have little training and few in-depth relationships with the physician and patients. The family physician serves as the agent of a larger system whose role is to feed patients to subspecialty services and hospital beds. The family physician is not responsible for patient panel management, community health, or collaboration with public health.”

With these definitions and role in mind, why bother to have a discussion among the chairs of academic departments of family medicine? As I pursue my work involving various re-design projects across and beyond our country, I am privileged to peer into things going on in health care, interact with students, residents, fellows and multiple

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generations of physicians in various specialties. I’ve noticed that overall, family medicine, particularly academic family medicine, is tilting toward the foil role—perhaps yielding to the gravitational pull of the medical-industrial complex and its needs and

• preferences. Let me also offer a few ver-batim quotes from attendees at a conference

focused on personal physicians to provide further reasons to contemplate the question, “will people in the United States have a doctor?” Quote 1

“The accelerating advance of medical science has worked many wonders in our lives. We are frequently reminded of the progress—new skills, new drugs, new equipment—that is bearing fruit in better health and longer life for us all. Everyone assumes that only more such scientific knowledge is required in order to cope with diseases that remain incurable today. But, ironically, the progress of science is not without some saddening side effects. For one thing, no single doctor can hope to stay abreast of the torrents of new knowledge so that doctors must limit their practices to an ever smaller range of illness. There is growing concern that the fragmentation of care among many specialties may well jeopardize the personal relationship between doctors and patients, built as it must be on long-term cooperation in health as well as in sickness. There is increasing realization that such a close relationship can mean not only quicker and more accurate diagnosis, but also more effective treatment. In addition, although doctors have less ‘time to listen,’ patients have higher expectations of medicine and make more demands on their physicians.” [Arthur H. Harlow, Jr, President GHI, Inc.]

Quote 2

“The personal physician . . . is now in a situation where he cannot practice . . . as he should. Society or medicine is not organized to give him the help he needs. He cannot function alone. He needs the help of nurses, social works and so forth, and in a very few situations is the

• rganization such that it is attractive for a person to move into.” [Thomas Turner, MD Dean,

Johns Hopkins University School of Medicine]

Quote 3

“The force for the development and the support of the personal physician as the physician of first contact, primary physician, the continuity physician, the referring physician, the receiving physician, the coordinating physician, the continuous family doctor and personal physician, the main force for that will, I think, have to come from outside the medical profession and outside the forces of its own technology." [T.S. Falk, PhD, Professor of Public Health and Epidemiology, Yale University Medical School]

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Quote 4

"Many of the problems when you discuss the future of the personal physician, are problems of ultimate social and moral significance in modern democracy. They go very closely to the ideals around which we might hope that a good society, even in this troubled century, might turn.” [Charles Frankel, PhD, Professor of Philosophy, Columbia University]

Quote 5

“The thing that concerns me . . . is the fact that the patient is in a serious state today because he feels that he has no one in his corner, no one who understands him . . . he leaves the doctor’s office confused, or, on the other hand, having a false sense of his own good health.:” [William U. McClenahan, MD. Senior Attending Physician, Chestnut Hill Hospital.]

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“Almost every social problem I know would be easily solvable if there were no human beings

• involved. And most medical problems, too, would be easy if there were no human beings
• involved. They would be easy because even if you were wrong, nothing of great value would

have been lost. But so long as human beings are involved, and the presence of the patient as an individual living human being is taken to be a matter of some importance, the future of the personal physician had better be guaranteed.” [Frankel again]

Now, I believe all of you know that the American Board of Family Medicine Foundation has established the G. Gayle Stephens Conference Series in honor of the poet laureate

• f family medicine and his many contributions to the intellectual basis of family medicine

and medicine in general. And I also believe you know that the inaugural conference of this series was the fourth Keystone Conference held in June of 2015 in Keystone,

• Colorado. You may have surmised that these conference quotes came from attendees
• f that conference, and if so, you would be wrong. None of them are from Keystone IV.

All are from a 2-day conference held in New York City titled, “The Future of the Personal Physician.” The quotes are from the President of Group Health Insurance of New York (the sponsor of the conference), a dean from Johns Hopkins University, a professor of public health and epidemiology from Yale University, a professor of philosophy from Columbia University, and a Senior Attending Physician from Chestnut Hill Hospital. The conference proceedings were published in1964—somewhat explaining the persistent neglect of feminine pronouns.

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Keystone IV was conceived and conducted more than a half century later, with no knowledge of this 1962 conference. Robin Gottler uncovered it in the library of a former chair of the department of family medicine at Case Western and sent it to me after learning about Keystone IV. I believe you will agree with me that the issues raised in 1962 persist today. When placed into the context of being a chairperson of a department of family medicine in a country that while over-spending on health care has marched to dead last in life expectancy at birth for baby boys and girls—compared to peer nations, at least wondering for a moment about how we are going about doing health care seems sensible. And perhaps, maybe, the ancient notion of a personal physician might merit reconsideration as part of corrective actions. Please, let me remind you of the purpose of Keystone IV. Like prior Keystone meetings, it was not a strategic planning meeting, but rather an invitational, intergenerational, extended conversation about a question, specifically: “What promise(s) will personal physicians make publicly, and keep, in the evolving US health care system, particularly as to when and where they will be there for their patients?” Some of you may connect this question to Keystone III and see it as something of a reprise of Dr. Bill Phillips exclamation that “you can pretend to know, you can pretend to care, but you can’t pretend to be there.”

• Dr. Freddie Chen, who as a member of the conference planning committee proposed

this focus for Keystone IV, enriched this question at the conference with the question, “What is it about relationships, time, and place that is so central to being a personal physician?” I next want to share with you some answers to the Keystone IV conference question as discerned by the participants in advance of their being published as a written record of the conference:

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Miller We promise to always be present, as clinically competent partners, and work with you, your family and friends and our communities for better health. It is a collective promise by our personal, relationship- centered team. My individual promise is to ensure the collective

• ne. This is a dream that will not sleep; a promise we will keep.

This is the hunger we will fulfill. Griswold Wherever care is delivered, we can promise to: meet and delight in patients where they are; continue to cultivate communities of solution; remember the place of touch in healing. Loxtercamp Let’s pledge to give patients our undivided time. Let’s create treatment plans that are built on the bedrock of trust. And let’s secure these promises with a commitment to regain control over our professional time and the rule by which we govern it. Stream et al We must renew promises: our promise to maintain a broad scope of training and practice for family physicians to meet patient and community needs; our promise to collaborate with other primary care professionals and stakeholders outside of medicine; our promise to embrace patients and patient advocates as partners in

• ur work at the patient / organizational / systems level; and our

promise to be leaders in our communities with regard to bridging public and behavioral health. Waters et al First and foremost, we will be unwavering in our commitment to relationship, to flatten the power differential between patient and health team, and to be present especially at those critical transitions

• f care when our patients need us most. We will also remember

that our purpose as healers and our commitment to the whole patient includes a call to action outside our clinics. We promise to advocate for relationship-centered care for all as the foundation for a new health care system. Inherent in this goal is working towards universal access to health care, so that those currently unable to establish a relationship with a health team can do so. Innovations at the clinic- and system-level that enhance accessibility, continuity and coordination of care will ultimately enhance the strength of patient-care team relationships. We also acknowledge our mandate to bear witness to the powerful impact of the social, economic and political determinants of health, to persistent institutional racism, and to unique hardships faced by those new to this country.

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Anthropologist Rebecca Etz attended and observed Keystone IV, studied the conference recordings and written promises proposed by some forty attendees, and synthesized what may well be seen as the consensus result from Keystone IV. It reads almost like an oath of the personal physician: Etz I will be held accountable to those who need me. I will be there for

• you. Attentive and fully present. I will care for you when you have no

need and you do not ask. I will center that care in your lived experience of health and illness, knowing you over time. I will be here for you now, over time and across distance, in ways that foster the feeling of wholeness and belonging. I will provide centered care, personal care, expert care, and experiential care, despite economic, technological and political distractions that threaten to enter the healing place we create together. Because I know you, I will be able to use the best knowledge, best tailored to meet our shared understanding of your goals and aspirations. As with prior Keystone Conferences, many and probably most attendees left—changed in some way. A long standing leader of internal medicine departed indicating that she had never attended a conference of such importance where physicians so candidly shared their lived experience in medical practice with others. Some left adamant about creating action plans and others committed to seeding Family Medicine for America’s Health with ideas. The newest generation of family physicians and more experienced physicians in other specialties confessed they had never heard of Gayle Stephens and did not understand where family medicine came from, why it exists, and that they “had to come to Keystone to learn this” because they never got it in school or residency. Most physician attendees reported a sense of renewal and renewed connection to why they went into medicine and other attendees voiced hope for robust personal physicians for themselves and those they love. As with previous Keystone conferences, there will be a written record of Keystone IV, this time as a JABFM Supplement comprised of about a dozen papers authored by participants, across the generations. Already posted on the conference website where they will be retained indefinitely are video recordings of the conference as streamed live to the internet. Soon, there will be on the website a summative video aiming to capture key insights from the conference and a couple of short, “trigger” videos that might be useful in teaching settings. As a former chair of a department of family medicine sensitive to the responsibilities you have, I want to pose 3 questions both for discussion now at this meeting and possibly

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for ADFM as an organization to consider addressing further, perhaps in a “mini Keystone” format as has been done at least in Missouri and Wisconsin:

• 1. On a scale of 1-5 with 5 being the highest priority, where does producing
• utstanding personal physicians fit in your department’s mission?
• 2. A. If preparing personal physicians merits being a high priority for your

department, what enables you to do so and what compromises your efforts, and particularly---how does the AHC support/hinder your efforts to prepare and position superb personal physicians? B. If preparing personal physicians does not merit a high priority for your department, what are your higher priorities?

• 3. If preparing personal physicians merits any priority for your department, what

adjustments “back home” do you think are necessary for success? Let me conclude with a recommendation to study the recently published book, Team of Teams by General Stanley McChrystal et al derived in part from experience in Iraq and Afghanistan, and do so while holding in your mind the possibility that personal doctoring might be an essential component of information-age health care, contending with and marshalling to good effects the new ways humans relate to each other. You might read this book wondering if personal doctoring might be part of organizational approaches that help people adapt to unpredictability and inescapable complexity, exploiting knowledge and technology to relieve suffering and promote individual and community well-being. After John, Tony, and Ardis contacted me about joining you here today, I came across a couple of quotes that made me think about the nature of chairing academic departments these days. I want to share them as a bit of further context as we move now to reactions and conversation. From Rev William Sloane Coffin: “The primary problems of the planet arise not from the poor, for whom education is the answer; they arise from the well-educated, for whom self-interest is the problem.” From Robert Browning: “A man’s reach should exceed his grasp, else what’s a Heaven for!” Thank you for your tolerance and attention. LAG 021816